Accolade Healthcare Danville

In the surveyor’s words

From the most serious findings on record at Accolade Healthcare Danville, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 5, 2025

  Based on Observation, Interview, and Record Review the facility failed to prevent a fall with injury by failing to provide adequate staff assistance during a therapy session for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling forward out of a bed and landing on the floor and hitting R1's head on the floor. R1 sustained a laceration to the head which required emergency treatment and 15 staples to close. Findings Include:R1's Emergency Department Notes dated 10/31/25 at 6:15PM document R1 has a laceration and received 15 staples to the frontal part of the head due to a fall. R1's Progress Note dated 10/31/25 documents Therapy informed this nurse that resident fell. […]

• Actual harm, isolatedF686Feb 19, 2025

  Based on observation, interview, and record review the facility failed to develop and implement skin and pressure relieving interventions, evaluate nutritional status, maintain wound dressings, and accurately document wound assessments for three (R1, R3, R4) of three residents reviewed for pressure ulcers in the sample list of four. These failures resulted in R4 developing a stage two pressure ulcer that deteriorated into an unstageable pressure ulcer. Findings include: The facility's Skin and Wound Management Guidelines dated April 2023 documents preventative measures will be implemented for residents who are at risk for developing wounds and aggressive wound management will be initiated for wounds/pressure ulcers. […]

• Actual harm, isolatedF684Jul 30, 2024

  Based on interview and record review the facility failed to routinely assess and monitor a bruise/hematoma (bruising with blood pooling underneath the skin), update the physician, and assess and measure post-surgical wounds upon readmission for one of three residents (R1) reviewed for wounds in the sample list of four. This failure resulted in R1's left foot bruise/hematoma becoming infected and requiring hospital operative incision and draining (I&D). Findings include: R1's Care Plan dated as reviewed 5/13/24 documents R1's diagnoses include Peripheral Vascular Disease and Type 2 Diabetes Mellitus. R1's Nursing Note dated 6/1/2024 at 9:48 AM documents a fresh, purple bruise was found on the top of R1's left foot that measured 3 centimeters (cm) by 1 cm. […]

• Actual harm, isolatedF689May 7, 2024

  Based on observation, interview and record review the facility failed to implement effective fall interventions in three (R1, R2, and R3) of three residents reviewed for falls. These failures resulted in R1 sustaining a head laceration with an arterial bleed, requiring nine sutures and R2 sustaining bilateral fractured wrists resulting in decreased independence, both as the result of falls. Findings include: The Facility Accidents and Incidents Policy dated 11/2023 documents, The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate intervention to affected parties. […]

• Actual harm, isolatedF689Jan 9, 2024

  Based on observation, interview and record review, the facility failed to provide a safe, functional air mattress to prevent a fall from bed; failed to thoroughly investigate the environment to determine a targeted root cause to repair or replace the air mattress for R2; and failed to safely transfer a resident (R5) by full mechanical lift, from a wheelchair to recliner chair. These failures resulted in R2 sustaining a head injury and laceration requiring emergency medical care at a local hospital and R5 to get hit in forehead with mechanical lift equipment causing mild swelling and abrasion. R2 and R5 are two of five residents reviewed for accidents/accidents on the sample list of 11. Findings Include: 1.) R2's Admission Record documents R2's initial admitted as 11/20/23. […]